Coronary Artery Calcium Scoring Does Not Add Prognostic Value to Standard 64-Section CT Angiography Protocol in Low-Risk Patients Suspected of Having Coronary Artery Disease

Published Online:https://doi.org/10.1148/radiol.10100886

In terms of prognosis, coronary artery calcium scoring may no longer need to be incorporated into the cardiac CT protocol in this population, considering the radiation exposure.

Purpose

To evaluate the prognostic outcome of cardiac computed tomography (CT) for prediction of major adverse cardiac events (MACEs) in low-risk patients suspected of having coronary artery disease (CAD) and to explore the differential prognostic values of coronary artery calcium (CAC) scoring and coronary CT angiography.

Materials and Methods

Institutional review committee approval and informed consent were obtained. In 4338 patients who underwent 64-section CT for evaluation of suspected CAD, both CAC scoring and CT angiography were concurrently performed by using standard scanning protocols. Follow-up clinical outcome data regarding composite MACEs were procured. Multivariable Cox proportional hazards models were developed to predict MACEs. Risk-adjusted models incorporated traditional risk factors for CAC scoring and coronary CT angiography.

Results

During the mean follow-up of 828 days ± 380, there were 105 MACEs, for an event rate of 3%. The presence of obstructive CAD at coronary CT angiography had independent prognostic value, which escalated according to the number of stenosed vessels (P < .001). In the receiver operating characteristic curve (ROC) analysis, the superiority of coronary CT angiography to CAC scoring was demonstrated by a significantly greater area under the ROC curve (AUC) (0.892 vs 0.810, P < .001), whereas no significant incremental value for the addition of CAC scoring to coronary CT angiography was established (AUC = 0.892 for coronary CT angiography alone vs 0.902 with addition of CAC scoring, P = .198).

Conclusion

Coronary CT angiography is better than CAC scoring in predicting MACEs in low-risk patients suspected of having CAD. Furthermore, the current standard multisection CT protocol (coronary CT angiography combined with CAC scoring) has no incremental prognostic value compared with coronary CT angiography alone. Therefore, in terms of determining prognosis, CAC scoring may no longer need to be incorporated in the cardiac CT protocol in this population.

© RSNA, 2011

References

  • 1 Meijboom WB, van Mieghem CA, Mollet NR, et al.. 64-slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease. J Am Coll Cardiol 2007;50(15):1469–1475. Crossref, MedlineGoogle Scholar
  • 2 Detrano R, Guerci AD, Carr JJ, et al.. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008;358(13):1336–1345. Crossref, MedlineGoogle Scholar
  • 3 Budoff MJ, Shaw LJ, Liu ST, et al.. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 2007;49(18):1860–1870. Crossref, MedlineGoogle Scholar
  • 4 Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology 2003;228(3):826–833. LinkGoogle Scholar
  • 5 Nasir K, Shaw LJ, Liu ST, et al.. Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality. J Am Coll Cardiol 2007;50(10):953–960. Crossref, MedlineGoogle Scholar
  • 6 Scholte AJ, Schuijf JD, Kharagjitsingh AV, et al.. Prevalence of coronary artery disease and plaque morphology assessed by multi-slice computed tomography coronary angiography and calcium scoring in asymptomatic patients with type 2 diabetes. Heart 2008;94(3):290–295. Crossref, MedlineGoogle Scholar
  • 7 Hoffmann MH, Shi H, Schmitz BL, et al.. Noninvasive coronary angiography with multislice computed tomography. JAMA 2005;293(20):2471–2478. Crossref, MedlineGoogle Scholar
  • 8 Miller JM, Rochitte CE, Dewey M, et al.. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 2008;359(22):2324–2336. Crossref, MedlineGoogle Scholar
  • 9 Budoff MJ, Dowe D, Jollis JG, et al.. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008;52(21):1724–1732. Crossref, MedlineGoogle Scholar
  • 10 Meijboom WB, Meijs MF, Schuijf JD, et al.. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 2008;52(25):2135–2144. Crossref, MedlineGoogle Scholar
  • 11 Ostrom MP, Gopal A, Ahmadi N, et al.. Mortality incidence and the severity of coronary atherosclerosis assessed by computed tomography angiography. J Am Coll Cardiol 2008;52(16):1335–1343. Crossref, MedlineGoogle Scholar
  • 12 Gibbons RJ, Balady GJ, Bricker JT, et al.. ACC/AHA 2002 guideline update for exercise testing: summary article—a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40(8):1531–1540. Crossref, MedlineGoogle Scholar
  • 13 Bongartz G, Golding SJ, Jurik AG, et al.. European guidelines on quality criteria for computed tomography. Publication EUR 16262 EN. www.drs.dk/guidelines/ct/quality/htmlindex.htm. Accessed February 20, 2010. Google Scholar
  • 14 Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990;15(4):827–832. Crossref, MedlineGoogle Scholar
  • 15 DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988;44(3):837–845. Crossref, MedlineGoogle Scholar
  • 16 van Werkhoven JM, Schuijf JD, Gaemperli O, et al.. Incremental prognostic value of multi-slice computed tomography coronary angiography over coronary artery calcium scoring in patients with suspected coronary artery disease. Eur Heart J 2009;30(21):2622–2629. Crossref, MedlineGoogle Scholar
  • 17 Min JK, Shaw LJ, Devereux RB, et al.. Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol 2007;50(12):1161–1170. Crossref, MedlineGoogle Scholar
  • 18 Carrigan TP, Nair D, Schoenhagen P, et al.. Prognostic utility of 64-slice computed tomography in patients with suspected but no documented coronary artery disease. Eur Heart J 2009;30(3):362–371. Crossref, MedlineGoogle Scholar
  • 19 Ho JS, Fitzgerald SJ, Stolfus LL, et al.. Relation of a coronary artery calcium score higher than 400 to coronary stenoses detected using multidetector computed tomography and to traditional cardiovascular risk factors. Am J Cardiol 2008;101(10):1444–1447. Crossref, MedlineGoogle Scholar
  • 20 Hamon M, Morello R, Riddell JW, Hamon M. Coronary arteries: diagnostic performance of 16- versus 64-section spiral CT compared with invasive coronary angiography—meta-analysis. Radiology 2007;245(3):720–731. LinkGoogle Scholar
  • 21 Hausleiter J, Meyer T, Hadamitzky M, et al.. Non-invasive coronary computed tomographic angiography for patients with suspected coronary artery disease: the Coronary Angiography by Computed Tomography with the Use of a Submillimeter resolution (CACTUS) trial. Eur Heart J 2007;28(24):3034–3041. Crossref, MedlineGoogle Scholar
  • 22 Scheffel H, Alkadhi H, Plass A, et al.. Accuracy of dual-source CT coronary angiography: first experience in a high pre-test probability population without heart rate control. Eur Radiol 2006;16(12):2739–2747. Crossref, MedlineGoogle Scholar
  • 23 Dewey M, Zimmermann E, Deissenrieder F, et al.. Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and maintained diagnostic accuracy: comparison of results with cardiac catheterization in a head-to-head pilot investigation. Circulation 2009;120(10):867–875. Crossref, MedlineGoogle Scholar
  • 24 Palumbo AA, Maffei E, Martini C, et al.. Coronary calcium score as gatekeeper for 64-slice computed tomography coronary angiography in patients with chest pain: per-segment and per-patient analysis. Eur Radiol 2009;19(9):2127–2135. Crossref, MedlineGoogle Scholar
  • 25 U.S. Nuclear Regulatory Commission. 10 CFR 20.1003 Definitions. http://www.nrc.gov/reading-rm/doc-collections/cfr/part020/part020-1003.html. Accessed January 12, 2009. Google Scholar

Article History

Received May 5, 2010; revision requested June 10; revision received September 13; accepted September 28; final version accepted November 2.
Published online: Apr 2011
Published in print: Apr 2011